This study compares rates of trial of labor after Cesarean delivery (TOLAC) and rates of successful TOLAC between 1990 and 2009. Serial cross-sectional analyses were performed using the National Hospital Discharge Survey data to compare rates of TOLAC and TOLAC success between 1990 and 2009. Joinpoint regression was used to assess trends over time, and logistic regression with marginal effects was used to examine the unadjusted and adjusted significance and magnitude of trends. The rate of TOLAC reached a high of 51.8 % (95 % CI 47.8-55.8 %) in 1995 and a low of 15.9 % (95 % CI 13.8-18.0 %) in 2006, declined, on average, 4.2 (95 % CI -4.8 to -3.9) percentage points per year between 1996 and 2005. Rates increased significantly from 1990 to 1996 and 2005 to 2009. TOLAC success was at its highest rate in 2000, 69.8 % (95 % CI 65.2-74.3 %) and its lowest in 2008, 38.5 % (95 % CI 28.1-48.8 %). The rate of TOLAC success increased significantly between 1990 and 2000, but declined thereafter an average of 3.4 % points per year (95 % CI -4.3 to -2.5). The rate of TOLAC in the US decreased between 1996 and 2005 and the rate of successful TOLAC has declined from 2000 to 2009.

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula. In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism. On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.

In 2008, the majority • of visits to primary care delivery sites (84%) occurred in physician offices, 11% in hospital outpatient departments (OPDs), and 5% in community health centers (CHCs). Patients with Medicaid, • State Children's Health Insurance Plan (SCHIP) or no insurance accounted for a higher percentage of visits to CHCs (56%) and OPDs (40%) than to physician offices (17%). CHCs had a higher age-• adjusted percentage of visits by patients with one or more chronic conditions (56%) compared with visits physician offices (49%) and OPDs (49%). Interest in access, utilization, and quality of primary care has increased due to its potential to prevent more serious health-related events (1-4). This report compares care delivered in physician offices, hospital outpatient departments (OPDs) and community health centers (CHCs). In 2008, 62% of the 1.1 billion ambulatory care visits were made to primary care delivery sites (5-7). Although primary care may be provided by any specialty, our analysis is limited to visits to office-based physicians, CHC providers, and OPD clinics specializing in internal medicine, family or general practice, general pediatrics, and general obstetrics and gynecology.